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~ I A II: Ur- NI:VV Y UHf\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
. ,
I JIIM'~ a AnIta
MIDDLE CURRENT SURNAME
COUNTY n.~
CITYrrOWN w.pp~
~~J.;.;~ 1W
~5~~J~R 136
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 1nR.~ 7fI7Q
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. ~)VnrY B.~
C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE
AND Pough.-
SPECIFY e
D. STREET ADDRESS g AMAra Road
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 46 3B. OATE OF BIRTH
ZIP 12!mO
DYES l3I"NO
M
4. EMPLOYMENT
A. USUAL OCCUPATION A.........nt l1i~nr Of Tnlinif1g
B. TYPE OF INDUSTRY OR BUSINESS M T. A. Metro Nodb R R.
5. PLACEOFBIRTH ~~tJN-Vor.k
6. FATHER
A. NAME Wnwra~ I Aft ~~
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Comella N. Egle
B. COUNTRY OF BIRTH Germeny
8. NUMBER OF THIS.MARRIAGE ~
9. PREVIOUS MARRIAGES
A.' NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE' CIVIL ANNULMENT DEATH
1 a a
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST M~~RIAGE E~DED? . W .' 11 / 1CMn'
MONTH DAY y-rr-
D. ARE ANY FORMER SPOUSE(S) ALIVE? [JIIJ'es 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY,IF NOT USA) SELF SPOUSE
03111/1997 WIlle PlaIns. New York
21. SIGNATURE OF GROOM ~
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
J:f1In~ M 'NundP-rliclt
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Bova
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER MAdtR.QR~
12. RESIDENCEA. ~rnrtr B. ~
C. CHECK ONE 0 CITY o.lIItOWN 0 VILLAGE
AND P h~
SPECIFY ftItg ___....-e
D. STREET ADDRESS g AMAra Road ZIP 125M
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES 0;00
13. A. AGE 50 13.B. DATE OF BIRTH MeW / ~ -"1~
14. EMPLOYMENT
A. USUAL OCCUPATION Attnl'rH!f
B. TYPE OF INDUSTRY OR BUSINESS Finkelstein & Penner,
15. PLACE OF BIRTH~~"
16. FATHER
A. NAME .lnhn RI1ttWa Cridllnn
B. COUNTlRY OF BIRTH Italy
17. MOTHER
A. MAIDEN NAME Marga.. FeclerlcI
B. COUNTRY OF BIRTH II S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 . a
B. HOW DID LAST MARRIAGE END? (3) D~VORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH 12 (DR4 / ago1
D. ARE ANY FORMER SPOUSE(S) ALIVE? O~s 0 NO .'
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY,YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1210412OO1llergeft eo.lnly. N I
DEATH
a
1ST
2ND
3RD
0-"
o
o
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO B E
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York S bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only for the
24. TOWN OR CITY CLlERK
W
en
z
W
(,)
::i
~
{ SEAL }
'-v-I
NAME (PRINT)
S R T
1 CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
YEAR
MONTH
10:19"M
PM
10
1 0 CIVIL
28. PLACE WHERE MARRIAGE OCCURRE~
A. STATE NEW YORK B. COUNTY f nt:l m
LOCATION OF CEREMONy
(CHECK ONE AND SPECIFY)
'P CITY OF .. TOWN OF 0 VILLAGE OF
SPECIF'(P H iIJPsf#w/.J,o
I " e~-9/e 151'1 fI." j./IIlsor?
~